Informed Consent, Procedural Notes, & Patient Education

what are the 5 data points that must be included for minimal info to obtain consent?

-nature of condition

-Tx objectives

-Tx options

-possible outcomes

-risks

when should informed consent be obtained?

-before all medical interventions that have potential harm

what are the 5 steps of obtaining informed consent?

1: establish responsibility

2: set Tx goals

3: establish whether a cure is reasonable

4: select a Tx approach

5: sign consent form

are minors able to make healthcare decisions?

-no, they are deemed legally incompetent

what aspects of informed consent are needed for documentation?

-PARQ + Dx

-Procedure nature

-reasonable Alternatives

-Risks & benefits

-assessment of patient’s understanding with Questions

when can informed consent be waived (4)?

-emergency situations

-if the patient has signed a waiver of consent

-incapacitated patient

-court-ordered Tx

what should you do if a patient refuses Tx?

-document the refusal & the patient’s understanding of their refusal

-witness signature

what are the 5 situations where a child under 17yo would be considered competent & able to provide consent?

-marriage

-graduated HS

-have children

-emancipated

-serving in military

what is the purpose of a patient waiver of consent?

-patient acknowledges their relinquishment of the right to informed consent

what is the “reasonable physician” standard?

-responsibility is limited to disclosures that a health provider would make under the same circumstances

what is the “reasonable person” standard?

-provider is required to disclose all info that a reasonable person in the patient’s situation would consider impt

what is the “subjective” standard?

-provider addresses what this patient needs to know to make an informed decision

when should procedure notes be written?

-immediately after the procedure

what data points should be in a procedure note?

-demographic data

-procedure performed

-indications

-contraindications/allergies

-consent

-personnel

-anesthesia

-procedure description

-complications

-EBL

-findings/specimen

-instructions/follow-up & patient disposition

-name & sig

what is the only procedure where there is no EBL?

-injections